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Exclusive: Nurse prescribing facing raft of new challenges

  • 9 Comments

Nurse prescribers have become “embedded” in practice as their numbers continue to grow, but experts have warned their continued success is at risk from skill loss, outdated practice and the need for more education funding.

An investigation by Nursing Times gauged the progress made by nurse prescribing in recent years as well as looking at the challenges that it now faces.  To do this, we collected data on current prescriber numbers and spoke to some of the country’s leading nursing experts in the area.

“Why are we not supporting more nurses to prescribe. Nurses have got the knowledge to educate patients”

Molly Courtenay

The number of nurses that hold a prescribing qualification has grown steadily for the past decade – increasing by around 6% every year – from 43,000 in 2006 to almost 72,000 in 2015.

The gains are mostly down to more independent and supplementary nurse prescribers who, since 2006, have had access to the same drugs as doctors. They have increased in number from just under 10,000 nurses in 2006 to almost 34,000 in 2015.

Meanwhile, the number of district nurses, health visitors and school nurses who hold a community practitioner nurse prescriber qualification – meaning they have access to a restricted formulary – has increased marginally, from 33,000 in 2006 to 38,000 this year.

Experts have said the growth in nurse prescribers with access to the full British National Formulary is down to recognition by employers of the benefits they bring to patient care.

They told Nursing Times further increases in this part of the workforce could benefit patients with long-term conditions, in particular, and help to reduce pressure on GPs.

But they warned there were a range of challenges that needed to be addressed to ensure the “world class” nurse prescribing in the UK continued.

One academic questioned whether funding being ploughed into the training of physician associates, a new type of clinician popular with government, should instead be diverted to nurse prescribers.

“Why are we not supporting more nurses to prescribe,” said Molly Courtenay, professor in health sciences at Cardiff University and a former nurse. 

“Nurses have got the knowledge to educate patients… Plus nurses can prescribe whereas physician assistants can’t,” she said.

She added that it was “ a bit worrying” for nurses that physician assistants were usually being employed at a band 7 – normally the same pay grade as nurse prescribers – when their role did not include prescribing.

But Professor Courtenay said it was encouraging that evidence suggested a high proportion – around 70% – of nurse prescribers were using their qualification in an independent capacity, rather than using it a supplementary way, which included some doctor involvement.

She warned, however, that research had also shown around half of nurses with the community prescribing qualification were not using it in practice at all, due to the formulary being out of date.

“There’s a lot of literature saying that [the formulary] isn’t fit for purpose. It was put together in the ‘90s around 25 years ago,” she said, adding that she was working with the BNF to have it reviewed.

Matt Griffiths, visiting professor of prescribing and medicines management at Birmingham City University, echoed the concerns about outdated practice and skill loss within the community prescribing workforce.

“With school nurses – maybe they could be the right people for prescribing emergency contraception but it’s not on the formulary for them,” he said.

“Steady growth of the workforce is fine, but we need some money enabling people to gain CPD  within prescribing”

Matt Griffiths

He added: “Health visitors are very often involved with the care of children with constipation and the NICE guidelines say they should be using macrogols – but they can’t use them because they are not on the formulary list.”

He also said that to maintain the “world class” prescribing practice in the UK, more needed to be done to ensure registrants were accessing continuing professional development.

“Steady growth of the workforce is fine, but we need some money enabling people to gain CPD  within prescribing,” he warned.

“That is an issue,” he said. “Some trusts are very anti working with pharmaceutical companies. However, they are often the only ones putting money into education.”

Meanwhile, Teresa Kearney, a recently retired independent prescriber and director of primary care development at South Essex Partnership University Foundation Trust, said problems with recruiting into the nursing workforce as a whole created challenges for increasing prescriber numbers.

She noted nurse prescribers could not be directly trained and that they required many years’ experience before taking on the additional qualification.

“It has never been incentivised in any way,” she said. “It doesn’t have to be financially incentivised – it just needs to be recognised more in terms of the skillset people are developing with respect to being able to deliver holistic and autonomous care.”

“Patient group directions have become an industry and I’m not sure there is the same rigour round a PDG as with a signed prescription”

Barbara Stuttle

Barbara Stuttle, chair of the Association for Prescribers – formerly the Association for Nurse Prescribing – said nurse prescribers had “led the way” in non-medical prescribing and were now “very embedded” in healthcare practice.

But she said improvements to practice were still required, such as using patient group directions to supply or administer medicines to a group of patients with a specific condition.

“PGDs have become an industry [in keeping them up to date] and I’m not sure there is the same rigour round a PDG as with a signed prescription,” she said.

“I question whether nurses have had training for supplying drugs under the PGD… My view is we should get rid of PGDs and instead have nurse prescribers so you wouldn’t need the PGD,” she added.

  • 9 Comments

Readers' comments (9)

  • Maybe if pharmacology was taught better while at university, nurses would have a much more grounded knowledge of drug prescription. I have never seen a nurse do any prescriptions while in a hospital setting, which is probably to do with having more doctors around, but even within the community I didn't see many nurse prescriptions. Members of the public are still very wary of taking drugs from nurses, I'm not really sure how this attitude could be tackled.

    And to touch upon PAs being paid equally/more than NPs or ANPs, I find really annoying. Nurse practitioners have more independence and generally don't need to work below a doctor and have much more autonomy in their work, but God forbid you pay nurses accordingly. No wonder so many nurses are doing the PA course

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  • michael stone

    I think that physician associates will probably be allowed to prescribe in the future, if that role 'takes off'. I gather that such a change is 'up for debate'.

    All of this, seems in part to stem from a shortage of GPs [although money-saving doubtless features].

    Personally, it strikes me that physician associates should be qualified/allowed to prescribe, and that if senior nurses want to become PAs then fine: also fine, if PAs are well paid.

    Although for one aspect - the lack of enough GPs - I would prefer more GPs !

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  • I have been prescribed antibiotics by a nurse in a Minor Injuries Unit and had no qualms about receiving a prescription from a nurse. She seemed to know exactly what she was doing, knew what to prescribe for someone allergic to penicillin and gave clear instructions regarding the dosage etc.
    I can see no reason why a nurse should not be qualified to prescribe some drugs. They have to pass a course so the comment about nurses studying pharmacology in more detail at university doesn't really apply. I wouldn't want to be prescribed drugs by a recently-qualified nurse, anyway!

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  • I qualified as an independent nurse prescriber over three years, at considerable personal cost as the course was very intensive, and a cost of about £5500 to the NHS. I am only qualified to prescribe within my area of competence, which I fully understand and agree with, yet I have never been allowed to prescribe since qualifying. I have worked full-time for 12 years in the NHS in my specialist area and am very keen to prescribe. This would save time for the consultants and GPs I work with, and reduce anxiety and waiting times for my patients. It is crazy that I cannot prescribe, but the excuse given is that I need a consultant to act as a mentor, and no one has the time to work with me!! Enough said.

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  • I have also been registered as a non medical prescriber for many years but the only time I have been allowed to freely prescribe (safely I may add ) is when I recently worked in a GP practice where my qualification was seen as a godsend both by the doctors and patients alike. I have since returned to secondary care and I cannot even prescribe a simple analgesia in my band 7 Nurse Practitioner role. What a waste of my time and cost to the NHS when all my new employer needs to do is check the NMC register and see that my qualification is active. It beggars belief that newly qualified doctors can just go ahead and prescribe when experienced nurses who have to pass an extremely rigorous course are then prevented from using their hard earned qualification.

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  • I have been an independent prescriber in a walk in centre for over. 3 yrs now and have found this extremely useful towards patient care. I would not advise that student nurses to learn prescribing. Having done an intense course in prescribing after being a qualified nurse for over 20yrs you do need the experience and expertise to manage a wide variety of conditions to be a safe prescriber. There's no reason why students could not learn basic pharmacology as they should know and how drugs work when administering them to patients.

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  • michael stone

    Anonymous | 29-Sep-2015 4:55 pm

    Anonymous | 29-Sep-2015 8:21 pm

    I find those 'somewhat disturbing'. I'm struggling 'to find much sense' in the 'I am qualified to prescribe yet I cannot [in fact] prescribe' theme.

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  • very interesting comments, my point of view is that in my area of practice we are expected to prescribe and do on a band 6, there is no pathway for a progression to a band 7, we see very complex clients, we are expected to know the BNF backwards as we do not have a computer system that links to an electronic BNF, we are a nurse led centre and when we do have DRs in attendance, we often advise them on the correct pathway of care.

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